hi, welcome to gender analysis. in recentyears, prescription testosterone has become a booming industry around the world. from2001 to 2011, the percentage of men over 40 in the us who were prescribed testosteronereplacement grew from about 0.8% to 2.9% - more than a threefold increase. and data from 41nations shows that yearly testosterone sales have increased from $150 million in 2000,to $1.8 billion in 2011. meanwhile, chains of "low t clinics" focusing on testosteronetherapy have opened dozens of locations across the country. so, what's behind this growth?let's take a look at one commercial for prescription testosterone gel: "i have low testosterone. there, i said it.see, i knew testosterone could affect sex
drive, but not energy or even my mood. that'swhen i talked with my doctor. he gave me some blood tests - showed it was low t. that'sit. it was a number." companies selling these medications increasedtheir spending on testosterone ads from $14 million in 2011, to $107 million in 2012,using a snappy new name like "low t" and the promise of a quick and easy pick-me-up forolder men. if your t is low, you feel bad; if your t is higher, you feel good – right?this is the approach that's fueled an explosion in testosterone usage. the problem is, it'snot just a number. in reality, "low t" levels are uncertain, the symptoms are vague, andthe relationship between levels and symptoms really isn't so direct.
the concept of "low testosterone" impliesthere's a level that's considered low. interestingly, there isn't really a medical consensus onwhat that level is. a report by the american urological association described hypogonadismas a total testosterone level lower than 300 nanograms per deciliter. however, that samereport also defined "true hypogonadism" as less than 150 to 200, and later said thatlevels from 200 to 346 are in a "gray zone". other studies and sources have defined lowtestosterone as less than 230, 250, 280, 319, 325, or 350. one laboratory test considerslevels as low as 132 to be normal. the endocrine society actually acknowledged that their panelistscouldn't agree on 200 or 300 as a lower limit when deciding whether to treat older men whohave low testosterone symptoms. according
to one article in the cleveland clinic journalof medicine: "there is no general agreement on the acceptable normal range of testosterone".another article adds: "there are no absolute testosterone levels below which a man canunambiguously be stated to be hypogonadal." this is not a merely theoretical dispute.as dr. lisa schwartz pointed out, defining low testosterone levels as below 230 nanogramsper deciliter would classify 7% of men aged 50 or older as having low t. but moving thecutoff to below 350 would expand this to 26% of that population. meanwhile, there's a substantialgap between the testosterone levels that most medical authorities aim for during treatment,and the levels that "low t clinics" aim for. the endocrine society suggests that levelsof 350 to 750 nanograms per deciliter are
best, while the cleveland clinic recommendslevels of 400 to 600. however, dr. jeffrey life of cenegenics elite health prefers toaim for 800 to 1000, the apex clinic in oklahoma city lists a goal of 800, the new jersey virilitycenter recommends 600 to 800, and the total male medical center describes 800 to 1100as "optimal levels". more t clinics claims that levels over 700 "can profoundly improveyour quality of life by increasing your energy, mental clarity, sex drive, sleep quality,muscle mass, and overall health." so, one test might show that a man has low testosterone,while a different test indicates his levels are normal. another man might have levelsthat are firmly within all these "normal" ranges, but a "low t clinic" would think hestill needs more.
but low t levels are only half the story.what about the condition itself, and its symptoms? hypogonadism – the insufficient productionof testosterone in men - is a real condition. it can be caused by injuries, infections,certain medications, pituitary disorders, cancer treatment, inflammation, autoimmunedisease, genetic disorders, or just normal aging. its symptoms can include lowered sexdrive, erectile dysfunction, infertility, loss of muscle, decreased body hair, osteoporosis,tiredness, difficulty concentrating, and even breast growth. for men with hypogonadism,this is a serious issue. but when low testosterone is simply the result of aging, the symptomsare often nonspecific. for instance, fatigue, loss of libido, and difficulty concentratingcould be caused by low t, but this can also
be caused by depression. and companies sellingprescription testosterone frequently offer symptom-based screening online. websites forandrogel and testopel ask questions like, "do you have a lack of energy?", "have younoticed a decrease in your enjoyment of life?", "are you sad and/or grumpy?", "are your erectionsless strong?", and "are you falling asleep after dinner?" these screeners are based onthe androgen deficiency in aging males questionnaire, designed to detect low testosterone levelsin older men. but the adam questionnaire has some performance issues of its own. in thefirst study of the adam screener's accuracy, it was given to canadian doctors aged 40 to62, and it was found to have a sensitivity of 88% and a specificity of 60%. a test'ssensitivity refers to how likely it is that
someone with a condition will receive a positiveresult, and specificity refers to how likely it is that someone without a condition willreceive a negative result. so, this study showed that out of 100 men who do have lowtestosterone levels, 88 will get a positive result from the adam screener, and the other12 will receive false negatives – they'll be told that they don't have low testosterone,when they actually do. meanwhile, because the specificity in this study was 60%, thismeans that out of 100 men without low testosterone, 60 will get a negative result from the screener– but 40 of them will get a false positive. the test is broad enough to encompass a lotof the men who do have low testosterone, but also some who don't. this is not an isolatedfinding from one study. in seven studies from
2004 to 2013 using the adam questionnaire,its sensitivity ranged from 66.7% to 88%, and its specificity ranged from 14.8% to 36.6%.when men without low testosterone take these online screeners, it's possible that a majoritywill nevertheless be told that they do have low t. as one article explained: "...the adamquestionnaire will rarely miss the diagnosis in hypogonadal individuals, but will alsoincorrectly identify many nonhypogonadal men. the lack of specificity is not only due tothe fact that many positive responses in the questionnaire may be indicative of other conditionssuch as depression, but also because scores derived from these questionnaires do not predictor correlate well with measured free and total testosterone." a story in the new york timesbriefly touched on the origin of the adam
questionnaire. quote: "dr. morley recallsthat he drafted the questionnaire in 20 minutes in the bathroom, scribbling the questionson toilet paper and giving them to his secretary the next day to type up. he agrees that itis hardly a perfect screening tool." yet this is the tool that sellers of prescription testosteroneare using to encourage men to see a doctor – a tool that could be telling up to 85out of 100 healthy men that they might have low t. surprisingly, other screeners don'tdo much better. in various studies, the aging males' symptoms scale was shown to have asensitivity ranging from 54% to 96%, and a specificity ranging from 30% to 48.1%. a screenerused by the massachusetts male aging study had a sensitivity of 76% and a specificityof 49%. ultimately, the symptoms of low t
don't seem to be so strongly associated with,well, low t. this is especially concerning given that only 51% of men on testosteronetherapy have actually been diagnosed with hypogonadism, and only 75% have had a bloodtest to check their t levels within the past 12 months. but what about men who do have low testosterone?oddly enough, low t levels can often be asymptomatic – men with low t might not show any signsof it. for instance, in a study of hundreds of elite athletes, 16.5% of men were foundto have testosterone levels below normal. another study focused on 1,475 men in theboston area aged 30 to 79. 24% of them had total testosterone levels below 300 nanogramsper deciliter, but only 5.6% had low t levels
along with symptoms. so, of all the men whosetestosterone levels might be considered low, three out of four did not have significantsymptoms of low t. the massachusetts male aging study went into further detail, groupingmen aged 40 to 70 into three different ranges of testosterone levels. at baseline, in thegroup with total testosterone levels greater than 400, 40% had 3 or more symptoms of lowt. of the men with levels of 200 to 400, 42% had 3 or more symptoms. even among men withlevels below 200, only 53% had 3 or more signs of low t. so, a substantial number of menwith these symptoms don't actually have low t levels – and many men with low t levelsdon't have these symptoms. dr. ronald swerdloff points out that men's low t thresholds canbe diverse. quote: "one man might get low
libido at 325 milligrams per deciliter, whileanother might not get low libido until 450." all of these factors – vaguely defined levels,vaguely defined symptoms, and a vague relationship between the two – have come together tocreate a fertile environment for the overprescribing of testosterone. as a trans woman, witnessing the rise of the"low t" industry has been fascinating – and more than a little frustrating. the complexthat's emerged here is seemingly designed to ensure that as many men as possible willbe on prescription testosterone. a man might feel tired, and he happens to see a commercialabout how this could be low t. he'll go to a site like isitlowt.com, and a quiz thatmight be no more accurate than a coin flip
will tell him to see his doctor. and he'llmake an appointment at his local "low t clinic", where even normal ranges aren't consideredhigh enough. before you know it, we've got a billion-dollar market on our hands. butmany trans people require treatment involving sex hormones as well. as dr. abraham morgentalerwrites: "it could be said that testosterone is what makes men, men. it gives them theircharacteristic deep voices, large muscles, and facial and body hair, distinguishing themfrom women." so it's no surprise that trans men would often want more testosterone, andtrans women would often want to get rid of theirs and replace it with estrogen. yet ourexperiences of engaging with the medical system could not be more different from that of cismen seeking treatment for low t. a spokesman
for abbvie described campaigns like isitlowt.comas "disease state awareness initiatives". but there are no major marketing initiativesraising awareness of transition treatments, or running commercials suggesting that ifyou're tired and depressed, you might be transgender. none of these businesses are promoting websitesabout gender dysphoria, or offering unhelpful quizzes that tell a significant fraction ofcis people to talk to their doctor about transitioning. and there are no multi-state chains of clinicsfocusing exclusively on transition treatments – let alone telling cis people that evenif they're healthy, transitioning can make them feel even better. there is no overbroadpromotion of trans medications – because most of the time, we don't even have accessto the basics. medical transition is recognized
as effective and necessary by the americanpsychological association, the american psychiatric association, the american medical association,and the world professional association for transgender health. unlike "low t", transitioningisn't the subject of any real medical controversy. but if you haven't yet realized you're trans,you're not going to learn about it from a commercial break during monday night football.basic awareness - what it feels like, what you can do about it, and where to find treatment– is mostly provided by the community via ad hoc resources like internet forums andpersonal websites. there is no organized promotion, just everyday people trying to help each otherand offering what they know. it's entirely possible that the current best way to finda clinic is to go to reddit, find one of the
trans sections, and ask if anyone in yourarea knows a doctor who'll see you. that's how little institutional and corporate supportwe have. and if you do manage to find a clinic, it'soften very difficult to be seen or receive treatment in a timely manner. after the dayi first made an appointment with a therapist, it was 3 months before i had my prescriptionsin hand. and in my experience, that's on the lower end – one of my friends has been waiting8 months just to get an appointment with an endocrinologist. now, what if i had been lookingfor testosterone instead? i've had my baseline t levels checked, and depending on which "normal"range you choose to apply, they were potentially low even before hormones. theoretically, icould have gone to the clinic a few miles
from here that's offering a month of freetestosterone, told them about how little body hair and muscle mass i had to start with,and received my first injection within a matter of days. countries with universal healthcareseem to have similar issues with the availability of transition treatments. the nhs's interimgender protocol from 2013 states that receiving hormones will typically take 6 months afterthe first visit to a gender clinic. before that, just waiting for the first consultationcan take even longer. the nottingham clinic reports a waiting time of about 6 months,the sheffield clinic reports a wait of 49 weeks, and the charing cross clinic has awaiting list that's 12 months long. a 2012 audit of scotland's lothian clinic found awaiting time of 68 weeks. for perspective,
68 weeks after i made my first appointment,i had been on hormones for over a year. and a study by the nhs in 2013 found that patientsin northwest england traveled a median of 214 miles for their gender clinic appointments.that's about the same distance as driving from new york city to boston. the situationin canada isn't much better. in january 2013, the centre for addiction and mental healthin toronto stated there was a waiting time of one year for a first appointment. in august,the centre actually published an open letter asking family doctors to start prescribinghormone therapy for trans people. and by october of 2013, the star reported that their waitinglist had grown to 16 months. that's a long time to wait to see a doctor.
now, some people might think that this issimply a statistical inevitability – that trans people must be incredibly uncommon comparedto cis men with low testosterone, so naturally there are fewer resources available. but ifwe're really so rare, then in a world where even the private low t center already has53 clinics in 12 states, it should be trivial to provide for what little we need. yet inreality, we're not that rare. let's consider the prevalence of symptomatic low testosterone.thanks to uncertainty surrounding the symptoms and levels, this can be interpreted somewhatfreely. in 1999, the makers of androgel stated in marketing materials that hypogonadism affectsabout a million men in the us. in 2000, they estimated the potential market as 4 to 5 millionmen. and by 2003, they were claiming that
up to 20 million men had hypogonadism. meanwhile,a 2002 article in the urologic clinics of north america reported that hypogonadism affectsabout 1 in 200 men. an article in the medical journal of australia repeats this number,as does the sixth edition of practical general practice. and a study of nearly 3,000 menaged 40 to 79 found that only 2.1% had low testosterone with symptoms. now, what abouttrans people? a report by the williams institute cites figures showing that 0.1% to 0.5% ofthe population is trans. another report by the gender identity research and educationsociety in the uk estimated that 0.6% of people are trans, and an update showed that the numberof trans people seeking treatment is doubling every 6 and a half years. so, based on figureslike 1 in 200 men, or 2.1% of men aged 40
to 79, men with symptomatic low testosteronecould be 0.25% to about 0.5% of the population. even a more generous figure of 5.6% of menaged 30 to 79 is still only about 1.6% of the population. and trans people are around0.1% to 0.6% of the population. it may not be the same, but it's not that far off. from a public health perspective, the shortageof transition-related services makes little sense in light of the excessive promotionof testosterone for cis men. but from a marketing perspective, the reasons are obvious. testosteronehas been portrayed as affirming and enhancing masculinity. it offers the promise of youthfulvigor, greater fitness, and better sex. if you're a man, it'll make you even more ofa man. and it evidently hasn't been difficult
to find millions of men who want exactly that,even if they have no medical need for it. basically, testosterone is sexy. transitioningis too, in my opinion, but it seems like most people don't see it that way. if anything,they don't really want to see us at all. transitioning destabilizes the assumptions that are usedto market prescription testosterone. from one direction, it demonstrates that testosteroneand masculinity are for more than just cis men. from another direction, it representsthe elimination of masculinity on a physical, cellular level. rather than reinforcing commonnotions of masculinity, transitioning deconstructs them. and when people see someone who couldhave cultivated their masculinity, but instead chose the chemical opposite, they're oftenuncomfortable with that. convincing men to
take more testosterone is easy. selling transition?not so much. it's no coincidence that men with low t are asked to "step out of the shadows",while trans people are left in the dark. i'm zinnia jones. thanks for watching, andtune in next time for more gender analysis.
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